Baseline left ventricular ejection fraction associated with symptom improvements in both children and adolescents with postural tachycardia syndrome under metoprolol therapy

Anxiety and depression moods is involved in the pathogenesis of postural tachycardia syndrome

Objective

To explore the significance of anxiety and depression in children with postural tachycardia syndrome (POTS).

Study design

The study enrolled seventy-one children diagnosed as POTS in Beijing Children's Hospital Affiliated to Capital Medical University and Kaifeng Children's Hospital, aged 13 ± 2 years; The Self-Rating Depression Scale (SDS), the Self-Rating Anxiety Scale (SAS), the Hamilton Depression (HAMD) scale, and the Hamilton Anxiety (HAMA) scale were determined in POTS children. The POTS children were divided into two groups: anxiety/ depression group and non- anxiety / depression group according to the above scales scores. Heart rate (HR), and blood pressure (BP)were monitored by a Dash 2000 Multi-Lead Physiological Monitor.

Results

Twenty POTS children consisted of anxiety / depression group. Twelve were girls and eight were boys, with mean age of 14 ± 2 years. The non- anxiety / depression group included fifty-one POTS children aged 12 ± 2 years. Twenty-six were girls and twenty-five were boys. There were no statically differences in weight, gender, systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR in supine. The age and height of anxiety / depression group were higher than that in non- anxiety / depression group. The maxium HR (HRmax) in ten minutes of upright position or tilt, the change of HR from supine to upright (ΔHR), symptom scores in anxiety / depression group were significantly higher than that in non- anxiety / depression group. Four scale scores were correlated with symptom scores and ΔHR.

Conclusions

Anxiety and depression emotion might be involved in the pathogenesis of POTS.

Oral medications for the treatment of postural orthostatic tachycardia syndrome; a systematic review of studies before and during the COVID-19 pandemic

Background

Postural Orthostatic Tachycardia Syndrome (POTS) is a complex form of dysautonomia that presents with abnormal autonomic reflexes upon standing, leading to symptoms such as lightheadedness, tachycardia, fatigue, and cognitive impairment. The COVID-19 pandemic has brought renewed attention to POTS due to its overlap with post-acute sequelae of COVID-19 (PASC). Studies have found that a substantial percentage of COVID-19 survivors exhibit symptoms resembling POTS, elevating POTS diagnoses to previously unseen levels. We systematically reviewed the literature for existing high-quality evidence on potential interventions.

Methods

A systematic review of the literature was performed to identify studies of oral medications for the management of POTS. We searched for published manuscripts on the medical management of POTS through 6 April 2024 which met pre-specified inclusion criteria. We conducted quality appraisal and assessed risk of bias before extracting the data and performing synthesis to determine the current state of the evidence; particularly in the context of PASC.

Results

The study search and selection process identified 32 studies that met inclusion criteria, comprising randomized controlled trials, observational studies, and systematic reviews. Most included studies were judged to be of moderate to high quality, with largely low risk of bias. The most frequently studied medications were beta-blockers, ivabradine, and midodrine. Ivabradine and midodrine demonstrated the highest rate of symptomatic improvement, while beta-blockers showed the largest reduction in heart rate variability. Limited evidence was available for PASC-associated POTS, but findings suggest that treatments may have similar efficacy in both PASC and non-PASC cases.

Conclusion

Ivabradine, midodrine, and beta-blockers currently appear to be reasonable front-line choices in pharmacologic management of POTS (PASC associated and otherwise). Further RCTs that evaluate long term outcomes of medications are needed to further establish evidence based pharmacologic treatment approaches for POTS. Particular areas of inquiry include differential efficacy of recommended therapies based on POTS subtypes, and a need for treatments directly targeting the underlying autonomic nervous system dysfunction.

Systematic review registration

PROSPERO, identifier CRD42024505967, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=505967.

Management of Postural Orthostatic Tachycardia Syndrome in Pediatric Patients: A Clinical Review

Postural orthostatic tachycardia syndrome (POTS) is a chronic illness with unknown mortality and high morbidity, often diagnosed in the adolescent years. Published literature regarding POTS primarily focuses on the adult population, and guidance on treatment in pediatrics is sparse. The purpose of this clinical review is to evaluate the current literature on the management of POTS in pediatric patients. A search was conducted using the Cochrane database, Google Scholar, and PubMed. Studies were included if they evaluated the management of POTS, primarily in pediatric patients. Case reports and series were excluded. Eight published studies met the inclusion and exclusion criteria. To date, there are no US Food and Drug Administration-approved agents for the treatment of POTS. However, select pharmacological therapies have shown positive outcomes by addressing symptom origins, such as providing heart rate control, peripheral autonomic modulation, and targeting hypovolemia. Targeted pharmacological therapies studied in children and young adults include ivabradine, metoprolol, midodrine, pyridostigmine, intravenous crystalloid fluids, and fludrocortisone. Before adding pharmacotherapeutic interventions, non-pharmacologic interventions such as patient education, avoidance of symptom-triggering environments and medications, dietary fluid and sodium supplementation, exercise, and use of compression garments should be first attempted. Although the body of evidence for the management of POTS is expanding, additional research is needed to determine safe and efficacious dosing and establish clear guidelines for POTS in the pediatric population.

Poincaré Plot Can Be a Useful Tool to Select Potential Responders to Metoprolol Therapy in Children with Vasovagal Syncope

Purpose

To explore the value of the longitudinal axis/transverse axis ratio (L/T) of Poincaré plot in selecting children with vasovagal syncope (VVS) who were suitable for metoprolol therapy.

Patients and Methods

Children with VVS hospitalized in Peking University First Hospital between January 2012 and June 2019 and treated with metoprolol were retrospectively included as the training set, and children with VVS hospitalized between July 2019 and December 2020 were included as the validation set. The sex, age at admission, height, weight, body mass index, course of disease, syncope symptom score before metoprolol treatment, treatment duration, supine heart rate (HR), supine systolic pressure, supine diastolic pressure, peak HR during the head-up tilt test (HUTT), changes of HR during HUTT, hemodynamic response during HUTT, left ventricular ejection fraction, left ventricular fractional shortening and the L/T of Poincaré plot were compared between responders and nonresponders in the training set. Logistic regression analysis was conducted to explore predictors. Receiver operating characteristic curve was utilized to determine the value of the predictors for selecting potential responders. Finally, the value of the predictors was further verified.

Results

In the training set including 105 children, the L/T in responders was distinctly higher than that in nonresponders (P < 0.001), and there was no apparent difference between the two groups in other indexes. The L/T was statistically related to the efficacy of metoprolol (P < 0.001). The L/T >2.7 yielded a sensitivity of 88.2% and a specificity of 82.8% for indicating responders to metoprolol. Taking L/T >2.7 to select potential responders in another 43 children with VVS in the validation set, the sensitivity was 96.6%, specificity 71.4%, and accuracy 88.4%.

Conclusion

The L/T of Poincaré plot >2.7 can be a useful tool to select potential responders to metoprolol therapy in children with VVS.